On the Importance of Policy Mechanisms and Governance

Healthcare is going through change. Tremendous change.

Pay-for-performance, ACOs, EMRs, and a rapidly growing buffet table of regulatory bodies are forcing hospitals to adapt, and quickly. Hospitals and medical systems that can change quickly, adopt new standards, implement new tools, and provide low-cost, high-quality care will survive. Those that can't, won't.

So recently I've had several conversations with healthcare leaders who are looking for help making change. Some of the questions I've heard :

1. "What can I do to help us make change faster?"
2. "Why aren't our physicians (or committees) engaged?"
3. "What can I do to help improve communication?"
4. "What can I do to help standardize care in our organization?"
5. "What can I do to help us work together as a team?"
6. "What can I do to help us implement our Electronic Medical Record?"

Believe it or not, all of these questions are related by a thing called "hospital governance", and probably the most important tool for hospital governance is your policy manual.

Q : "Dirk, what is hospital governance? It sounds like a civics lesson, or something from Schoolhouse Rock."

Every organization, from Apple to IBM to small businesses to hospitals, have some form of governance - A set of tools to make decisions and take actions. Why? Someone has to make decisions, and then someone has to get work done. Unfortunately, organizing those people, who may have conflicting opinions, and getting them instead to work together can be challenging.

It's not enough to just have "talented staff". If your staff isn't working together the way you want them to, it might be a sign that you need to look at your governance structure.

So what is the biggest tool you have to govern yourself? Your policy manual. Unfortunately, the governance, policy manual, and policy mechanism of most hospitals is probably one of the least taught subjects in healthcare management.

Bear with me, I'm going to explain it in simple language. :)

Q : "So, Dirk, what's a policy? What's a procedure?"

A policy is a written goal of your organization. The procedure is the list of steps you take to achieve that goal. 

Good policy statements are short and sweet and clear. (A really good reference for this is Writing Effective Policies and Procedures : A Step-by-Step Resource for Clear Communication, by Nancy J. Campbell, 1998). Policy statements should not be paragraphs long - One or two sentences maximum. They should be clear and confident, e.g. :

     "All patients will get kosher meals..." or

      "All ED patients will get screened for influenza..." or

       "All pediatric patients will get weighed daily..." or 

        "All female patients over age 40 will be offered screening for..."

(You'll notice all of the above samples refer to subsets of patients, so they are all samples of clinical policies.) Good policy statements create clarity out of confusion, and help your staff understand your organizational goals.

The procedure, then, are the steps you take to achieve the goal stated in the policy, e.g. :

   "All pediatric patients will be weighed using the following procedure :

          1. Patient will stand on a digital scale

          2. Nurse will read digital readout on scale 

          3. Nurse will document the patient's weight in the patient's chart."

If you're not used to writing policies, it pays to invest in someone with training and experience. A good policy writer is worth their weight in gold. It's part art, part language, part human behavior, part communication, and part understanding workflows enough to write a good policy. Good policy writers can help create clarity out of confusion, and save your organization lots of money.

And you'll know if you have a good policy because someone on your front-line staff can read it, clearly understand it, and feel educated by the policy. 

When should you make a policy for something? Anytime your organization needs to standardize something.
      - Need everyone to get weighed on admission? Write a policy.
      - Need all patients over 50 to be given cancer screening? Write a policy.
      - Need all order sets to look the same? Write a policy.
      - Implementing a new tool that everyone will use the same way? Write a policy.

The danger, of course, in bad policies is that sometimes you can write too much. If you write too much, you can "paint yourself into a corner". This can be a problem when a regulatory body comes to look at your policies - In general, they look to make sure your policies reflect your practice. If you write too much, you can end up with policies that are too long, or that don't reflect your current practice, or that you have to keep amending/updating too frequently.

Again, this is why you should invest in someone trained in the art of policy writing, to help you write short, well-constructed, thoughtful, and clear policies. 

Q : "Can you give me a good teaching example of a policy and procedure?"

Sure. My favorite teaching example is this one :

POLICY : All patients will get a cupcake on admission.


PROCEDURE :

1. Kitchen staff will bake 100 cupcakes daily.
2. Couriers will bring cupcakes to floors.
3. Nurses will hand patients a cupcake when they are admitted.

What I like about this teaching example is it shows the thought that needs to go into a good procedure -

• It is a simple example which, while somewhat comical, people usually don't forget.
• It shows which staff will play which role (this is very helpful when figuring out who should review a policy before it is approved)
• "100 cupcakes" - It shows the thought that needs to go into writing an effective procedure. The trick : to include as much detail as is needed, and no more - (How many cupcakes will you need a day? How many admissions do you usually have?) 

This simple, well-written policy then helps directors budget for the time of their employees, and finance people to budget for the materials needed to make this policy work.

Q : "So what about the policy manual?"

The policy manual, then, is your total collection of policies. It should be treated like a sacred text. A good policy manual isn't torture - It's a source of education and communication across your organization. 

     - Have new staff you need to train? Use your policy manual!
     - Have old staff that you need to train? Use your policy manual!

     - Have directors who need to know "what's happening on the front"? Use your policy manual!
     - Have staff who need to know what the organization's rules/objectives are? Use your policy manual!

Q : "That seems pretty simple, is that it?"

Hardly.

Q : "What else do I need to know?"

Everything you do with those policies determines how your organization functions.

1. The way you organize your policies is important.

In a large organization, it's not enough to simply put all policies into one binder. You'll want to make a table of contents that guide your front-line staff to the policies they are looking for. Often, you'll want hospital-wide policies (apply to patients regardless of location), and department-specific policies (apply to patients in a specific location). And then you'll want to subdivide those chapters. (See my post about Policy Manuals Made Easy for an example of how you might divide your policy manual.)

2. The way you test your policies is important.

Before your policies are brought to a committee for approval, you'll want the policy writer to "test" them. That means, you'll want to know that the policy has been checked for accuracy, that the workflows are realistic, that the spelling has been checked, that the formatting is correct, that the proper stakeholders have been asked about the policy.

If you test your policies properly, before they are brought to a committee, there will be little discussion at your committee. Ever hear the statement, "Why are we discussing these details in the committee meeting?" The more time you spend in the "testing phase", the less discussion there will be in committee. I can't say enough about the importance of investing in testing, before a policy is brought to a committee for approval.

3. The way you approve your policies is important.

Depending on how you organize your policy manual, you will need a committee, or a group of committees, to approve your policies. A well-designed committee is small, efficient, and has a well-designed voting structure, run by a committee chairperson who understands basic rules of parliament and chairperson responsibilities. (For this, I recommend Robert's Rules of Order : Newly Revised - In Brief.)

If your committee has a well-designed charter (and voting structure), and is run by a chairperson who understands their responsibilities, the approval process will be efficient and the committee will make good decisions - ultimately they need to decide whether to approve, deny, or modify a policy.

And if you organize your committee structure properly, then subcommittees that struggle to approve a policy, or end up in a tie vote, should usually have a top-level committee that can discuss all of the policies that cause extensive discussion.

4. The way you publish your policies is important.

It's not enough to have well-written, approved policies in a binder in someone's desk or laptop. The policy manual has to be organized, comprehensive, and put in a place where everyone can access it. 

Every employee should know where it is, and should be introduced to it when they are hired.

5. The way you enforce and monitor your policies is important.

It's not enough to have well-written, approved policies in an organized, common policy manual. Managers need to enforce policies. Sure, during emergencies, there may be exceptions/emergencies where your front-line staff violate a policy, but when that happens, the employee should document the reason and managers/directors should ask "Why?". If someone is repeatedly violating a policy, it either means the policy is not appropriate/realistic, not properly designed, or the employee may need educating. (In my opinion, violating a policy should never be an automatic black mark against the employee - It should make the manager pause to reflect on the reason for the violation.)

It's also not enough to just schedule a re-review of policies every 2-3 years. Enforcement and monitoring is a continuous, ongoing job, which hopefully your managers are doing continuously. Those managers should be well-connected to your policy mechanism, so they can respond appropriately.

Finally, I will leave you with this Top-10 list of overheard comments which suggest your policy/governance mechanism may not be working the way you want it to :

1. "Why aren't our committees (or physicians) more engaged?"
2. "I don't know how to make a change around here" or "We can't change anything."
3. "Why didn't they tell us they were doing that?" (or "They have no idea what we're doing.")
4. "Who the heck passed that policy?" (or "That policy makes no sense.")
5. "Where is the policy manual?"
6. "I didn't know I was supposed to do that."
7. "Why do we have so many order sets?" (or policies, or protocols, or forms...)
8. "Our committee just decided against that, why are people still doing it?"
9. "Why aren't the owners updating their policies?" (or, "These policies are so old.")
10. "What can we do to standardize care?"

The good news is that organizing a policy manual and mechanism, and fixing your governance, can be a great experience that draws your entire staff together and rallies the troops. Feel free to leave your own stories about policy mechanism and governance!

Policy Manuals Made Easy

Hi folks. Happy new year! May 2011 be even better than 2010 was! :)

So I've been asked recently about where informatics policies should live, ideally, and I answered, "In the clinical policy manual."

That led to a follow-up question : "Dirk, what exactly is a clinical policy?"

This gets to the heart of a really interesting conversation about healthcare : The difference between a clinical policy and an administrative policy.

First, a word about policies in general.

Policies are probably one of the most misunderstood things in healthcare. Most doctors shudder when talk centers around, "We should make a policy for that" or "Do you know what the policy is for _______?".

A policy is a written, agreed-upon goal. (The "procedure", often attached to the same document, are the steps about how-to-get-to-that-goal.)

Policies, then, are your organization's written goals. That's why The Joint Commission asks about them, during inspections - They want to know how you organize, how you think, how you operate, etc. They also want to make sure the policies reflect the practices in your hospital.

Policies, if well-written, don't need to be painful. Policies help guide your staff behavior, they help communicate goals, and if they're well-written, they can also be used for training.

They also help protect your staff - Their activities are backed up by the organization's support for that behavior.

"Aha. So you were talking about maintaining policy manuals?"

That's right, I was. Thanks for reminding me. :)

So an interesting thing about healthcare, unlike private industries - We have two policy manuals, whereas most non-healthcare industries only have one.

"And what are those two policy manuals...?"

Interestingly, to maintain an average hospital, you need two general types of organizational control :

1. Clinical Policies - Those policies that refer to patients and patient care
2. Administrative Policies - Those policies that refer to employees and employee issues

Why do you need two? Well, an average healthcare organization is usually run by a Board of Trustees, who at some point made the decision, "We would like to run a hospital here."

To accomplish this, then, the Board usually needs :

1. A group of administrative people who are experts at running the hospital - Keeping it organized, hiring people, making sure supplies show up, paying the bills, setting up the budget, running the place, sending out bills to insurers, etc.
2. A group of clinical people who are experts at delivering patient care - Performing surgery, seeing patients, taking vitals, giving drugs, managing ventilators, etc.

And that's why most hospitals typically have two wings of government :

1. The Administrative Branch
2. The Clinical Branch

... and the policy manuals that are used to help run these two branches of government are :

1. The Administrative Policy Manual
2. The Clinical Policy Manual

"I see... So what else do I need to know?"

Well, to run an average hospital, then, you need to have both clinical and administrative policies that help guide your daily activities. The conflicts that sometimes arise, between these two branches of internal government, are sometimes very complicated - And, as a result, not every situation calls for a clear administrative or clinical policy.

"So how do I recognize an administrative policy from a clinical policy?"

An administrative policy statement usually refers to employees or employee issues, so they typically start with something like this :

"All employees at Acme Healthcare will..." or

"All physicians at Acme Healthcare will..." or

"All nurses at Acme Healthcare will..." or

"All ED staff at Acme Healthcare will..."

The collection of these administrative policies is typically kept in an administrative policy manual.

A clinical policy statement usually refers to patients or patient care issues, so they typically start with something like this :

"All patients at Acme Hospital will..." or

"All pediatric patients at Acme Hospital will..." or

"All ED patients at Acme Hospital will..." or

"All terminally ill patients at Acme Hospital will..."

The collection of these clinical policies is typically kept in a clinical policy manual.

"Aha. So how do you organize these policies, then?"

Every hospital has a slightly different way of organizing them, but I recommend a very simple system of organizing them :

1. Administrative Policy Manual

     a. General Hospital-Wide Administrative Policies

          - Human Resources

          - Safety

          - Information Management / Medical Records

          - Quality Management

          - (Other organizational administrative policies)

     b. Department-specific Administrative Policies

          - ED

          - Medicine

          - Surgery

          - OB/GYN

          - Pediatrics

          - (etc..)

2. Clinical Policy Manual

      a. General Hospital-Wide Clinical Policies

           - General Clinical Policies 

           - Quality Management

           - Nursing

           - Medical Records / Informatics

           - Laboratory

           - Radiology

           - Infection Control

           - Dietary

     b. Department-specific Clinical Policies

          - Medicine

          - Surgery / OR

          - OB/GYN

          - Pediatrics

          - ICU

          - (etc. etc.)

Again, as I said, every hospital does this a little differently, to address their different needs, but the general theme is that they are all generally clinical or administrative policies, and they generally either apply throughout the hospital or in a specific department or physical area.

"Dirk... That sounds like a lot of work, then!"

It is a lot of work. If every policy has to be approved by a person or committee, there's a lot of work that goes into maintaining these policy manuals. Many hospitals struggle with doing this efficiently.

The good news is that it doesn't have to be torture. By delegating each branch of policies to the right person/committee, you can divide up the work efficiently, for example :

1. Clinical Policies

      a. Hospital-wide Clinical Policies

           - General Clinical Policies = Approved by Medical Executive Committee

           - Nursing Policies = Approved by Nursing Committee

           - Medical Records / Informatics = Approved by Med Rec / Informatics committee

           - Pharmacy Policies = Approved by P&T Committee

           - Infection Control Policies = Approved by Infection Control Committee

      b. Department-specific Clinical Policies

           - Medicine - Approved by Medicine Committee

           - Surgery / OR - Approved by OR/Surgery Committee

           - ICU = Approved by Critical Care Committee

           - Pediatrics = Approved by Pediatric Committee

You'll notice the theme : Every branch of clinical policies will either need a committee or a person, delegated to maintain and approve that particular chapter of the policy manual.

And you'll notice how much work it takes to maintain all of this. Every time a drug gets recalled, every time the government creates new billing standards, policies have to be adjusted and re-approved.

The good news, if you do this well, is that you can use the policy manual as an education tool :

- For new staff who are orienting to your hospital

- For existing staff who would like to quickly find out daily operations

Finally, an important part about maintaining all of these separate chapters is that even if you delegate the maintenance of these chapters to different committees, it's imperative that you publish all of these policies in the same place. (That means, that all "active policies" are kept in one common place, where everyone can look at them.) By keeping the entire manual (all chapters) in one place, it :

1. Helps avoid policy conflicts between different departments, and
2. Helps make the policy manual a tool of organization and education for your staff.

Again, as I've said before, my advice is free and you get what you pay for. Every hospital does this a little differently, but I hope I've communicated the major themes. Would love to hear your stories and thoughts about best ways to organize a clinical and administrative policy manual!